Murtagh - Chest pain

Question 1

list the immediate life threatening causes of chest pain

Answer 1

myocardial infarction (MI) and unstable angina (acute coronary syndromes: ACS)
pulmonary embolism
aortic dissection
tension pneumothorax

Question 2

main DDx of ACS

Answer 2

aortic dissection, pericarditis, oesophageal reflux and spasm, biliary colic and hyperventilation with anxiety

Question 3

probability diagnosis of chest pain

Answer 3

musculoskeletal (chest wall)
psychogenic
angina

Question 4

serious disorders not to be missed for chest pain

Answer 4

cardiovascular:
- acute coronary syndromes
aortic dissection
- pulmonary embolism
neoplasia:
- lung cancer
- tumours of the spinal cord and meninges
severe infections:
- pneumonia/pleuritis (pleurisy)
- medications
- pericarditis
pneumothorax esp. tension
oesophageal rupture

Question 5

pitfalls (often missed) for chest pain

Answer 5

mitral valve prolapse
osesophageal spasms
gastro-oesophageal reflux disease
biliary colic/acute cholecystitis
herpes zoster
fractured rib (e.g. cough fracture)
spinal dysfunction
muscular tear

Question 6

rarities for chest pain

Answer 6

pancreatitis
Bornholm disease (pleurodynia)
cocaine inhalation
hypertrophic cardiomyopathy

Question 7

seven masquerades checklist for chest pain

Answer 7

depression
anaemia
drugs (e.g. cocaine)
spinal dysfunction

Question 8

is the patient with chest pain trying to tell me something?

Answer 8

consider functional causes, especially anxiety or panic with hyperventilation e.g. takotsubo syndrome), opioid dependancy

Question 9

causes of musculoskeletal/chest wall pain

Answer 9

chostochondritis, muscular strains, dysfunction of the sternocostal joints and dysfunction of the lower cervical spine or upper thoracic spine, which can cause referred pain to various ares of the chest wall

Question 10

red flags in acute chest pain

Answer 10

dizziness/syncope
pain in arms L>R, jaw
thoracic back pain
sweating
palpitations
syncope
haemoptysis
dyspnoea
pain on inspiration
pallor
past history - ischaemia, diabetes, hypertension

Question 11

severe infections that could cause chest pain

Answer 11

pneumonia/pleurisy
pericarditis
mediastinitis

Question 12

the chest pain patient who also has syncope

Answer 12

consider myocardial infraction, pulmonary embolus and dissecting aneurysm

Question 13

the chest pain patient who also has pain on inspiration

Answer 13

consider pleuritis, pericarditis, mediastinitis, pneumothorax and musculoskeletal pain

Question 14

the chest pain patient who also has thoracic back pain

Answer 14

consider spinal dysfunction, acute coronary syndromes, angina, aortic dissection, pericarditis and Gi disorders such as peptic ulcer, biliary colic/cholecystitis and oesophageal spasm

Question 15

things you should notice on general appearance of the patient

Answer 15

evidence of atherosclerosis (senile arcus, thickened vessels), pale and sweating (MI, dissecting aneurysm or pulmonary embolus), hemiparesis (? aortic dissection)

Question 16

the patient has reduced breath sounds on auscultation, hyper resonant percussion notes and vocal fremitus

Answer 16

pneumothorax

Question 17

on auscultation, the patient has friction rub

Answer 17

pericarditis

Question 18

on auscultation, the patient has basal crackles

Answer 18

cardiac failure

Question 19

on auscultation, the patient has aortic diastolic murmur

Answer 19

proximal dissection (aortic regurgitation)

Question 20

usefulness of electrocardiogram

Answer 20

diagnostic for ischaemia and infraction, but can show up normal in both

Question 21

pericarditis on ECG

Answer 21

characterised by low voltages and saddle shapes ST segment elevation

Question 22

pulmonary embolism on ECG

Answer 22

may be normal but if massive may show right axis deviation, right BBB and right ventricular strain

Question 23

exercise stress test

Answer 23

uses a treadmill to elicit ECG change with physical exertion to diagnose myocardial ischaemia

Question 24

exercise thallium scan

Answer 24

radionulceotide myocardial perfusion scan using thallium can complement the exercise ECG

Question 25

chest x-ray

Answer 25

routine chest x-ray is taken on full inspiration, ask for expiration film of pneumothorax is suspected

Question 26

blood glucose

Answer 26

tests association with diabetes

Question 27

serum enzymes

Answer 27

damaged necrosed myocardial tissue releases cellular enzymes, which are markers of this damage:
- troponin I and troponin T (the key marker) - on arrival and 2 hours later (ADAPT trial protocol)
- creatinine kinase (CK) and creatinine kinase myocardial bound fraction (CK-MB)
- myoglobin

Question 28

trasnthoracic echocardiography

Answer 28

can be used in the early stages of myocardial infraction to detect abnormalities in the heart wall motion, when ECGs and enzymes are not diagnostic

Question 29

transoesophageal echocardiography

Answer 29

more sensitive and it the investigation for dissecting aneurysm (immediate diagnosis), prosthetic valves and embolisation

Question 30

isotopes scanning

Answer 30

1. technetium-99m pyrophosphate studies
   - myocardium - to diagnose posterolateral myocardial infarction in the presence of bundle branch block
   - pulmonary - to diagnose pulmonary embolism
2. gated blood pool nuclear scan (radio nucleotide ventriculography) - this scan tests left ventricular function at rest and exercise in patient with myocardial ischaemia

Question 31

angiography (arteriography)

Answer 31

angiography, including CT angiogram, should be selective:
1. coronary - to evaluate coronary arteries
2. pulmonary - to diagnose pulmonary thromboembolism
3. coronary computed tomograph
4. MRI

Question 32

coronary artery disease includes

Answer 32

acute coronary syndromes - unstable angina and myocardial infarction
stable angina
other variants of angina